Prior Authorization Guidelines - Group Health Cooperative of Eau ...

Non-Emergent Surgeries
and Procedures
• Abortion
• Cancer clinical trials
• Circumcision not performed within one
week of birth
• Corneal transplants/Keratoplasty
• Dental anesthesia procedures or oral surgery not
performed in an office setting
• Essure sterilization not performed in
a doctor’s office.
• Gastric surgery for obesity (including consults,
testing, and assessments prior to surgery)
• Hyperbaric Oxygen Chamber Treatment
• Intra-discal electrothermal annuloplasty (IDET)
• Non-cardiac radiofrequency ablation for the
treatment of chronic pain
• Organ transplant including bone marrow transplant/
stem cell transplant
• Pain management services in an outpatient clinic
and outpatient hospital setting
• Plastic or reconstructive surgery including but
not limited to: blepharoplasty, ptosis repair,
panniculectomy, reduction mammoplasty,
breast implant removal, rhinoplasty, septoplasty,
scar revision
• Podiatric surgery not performed in the doctor’s
office or Skilled Nursing Facility
• Sclerotherapy/Endovenous Ablation
• Temporomandibular joint (TMJ) treatment
• Uvulopalatopharyngoplasty (UVPP, UPPP)
• Any service billed with an unlisted CPT or category
III procedure code, or previously unlisted CPT
or category III procedure code that now has a
permanent code
Use the Service Event Authorization Request form.
Out-of-Network Referral Requests
Any request for a member to obtain professional
services from an out-of-network provider must
be authorized by the Cooperative Health
Management Department.
Use the Out-of-Network Referral Event Authorization
Request form.
Out-of-Practice-Group Referral
Requests (as applicable)
Out-of-Practice-Group referrals for BadgerCare Plus
members to other Cooperative network providers
must be authorized by the Cooperative Health
Management Department.
Use the Out-of-Practice Group Referral Event
Authorization Request form
Outpatient Care
• Home care, except for one maternity follow-up visit
within 48 hours of hospital discharge for vaginal
delivery or 96 hours of hospital discharge for
C-section
• Hospice services
Use the Home Health Authorization Request form.
Outpatient Laboratory
• Any genetic testing such as DNA testing except:
• When billed in conjunction with amniocentesis
or
• Prenatal triple test or AFP: alpha-fetoprotien,
hCG: human chorionic gonadotropin, and Estriol
• When provided in conjunction with Bone
Marrow Biopsy
Use the Service Event Authorization Request form.
Outpatient Psychological Testing
Authorization for outpatient psychological testing
must be obtained by contacting the Cooperative’s
Health Management department at (800) 218-1745.
Outpatient Radiology not Performed at
the Time of an Emergency Department
Service or Visit, or an Inpatient or
Observation Stay
• MRI
• PET Scans / SPECT Scans
• CT Scans / CTA Scans
• Cardiac CT Scans for calcium scoring
Use the Service Event Authorization Request form.
Outpatient Therapies
Medically necessary short-term outpatient therapy
(when a covered benefit) must be prescribed and
monitored by a primary or specialty physician prior
to any services being rendered.
Prior authorization from the Cooperative is not
required for the first six outpatient visits, including
the initial evaluation, for Physical Therapy,
Occupational Therapy, Pulmonary Therapy and
Cardiac Therapy. If additional visits beyond the first
six are needed, prior authorization is required before
the seventh visit.
Use the appropriate authorization forms. For Cardiac
Therapy use the PT/OT/Cardiac Rehab/Pulmonary
Rehab Request form.
Prior authorization is required for speech therapy,
excluding the initial visit. Many commercial benefit
plans do not cover Speech Therapy. If speech therapy
is a covered benefit prior authorization is required for
any subsequent visits after the initial evaluation.
Use the Speech Therapy Request form.
Prosthetics and Durable Medical
Equipment (DME)
• Continuous Passive Motion Device (CPM)
• All other DME rental beyond 30 days or
accumulated $300 rental charges, per item
excluding nebulizers.
• New or used DME purchases over $300 billed
charges, per item excluding nebulizers.
• External and implantable infusion pumps and
supplies, including insulin infusion pump
Use the DME Authorization Request form.
Specialized Pharmacy Services
• All outpatient injections or infusions of medications
with billed charges of $500 and above, excluding
cancer chemotherapy, and drugs administered
in conjunction with diagnostic or radiographic
testing if the testing itself does not require
prior authorization,
• Any drugs or therapies used in the diagnosis
or the treatment of infertility, and
• Off-label drug use
Use the Service Event Authorization Request form.
© 2013 Group Health Cooperative of Eau Claire
group-health.com | P. 715.552.4300 or 888.203.7770 | F. 715.552.7202
GHC13269